Ossiculoplasty with an intact stapes: superstructure versus footplate prosthesis placement.

OBJECTIVES/HYPOTHESIS: Many techniques and prostheses are used for ossiculoplasty in the various situations of ossicular chain status that the surgeon may encounter in tympanoplasty procedures. The current study seeks to determine whether any particular technique or prosthesis used by the author demonstrates superior hearing results with fewer failures. STUDY DESIGN: Retrospective review. METHODS: This study retrospectively reviews a consecutive series of cases with intact stapes superstructures, with an intact malleus handle (Austin-Kartush group A) and without (Austin-Kartush group C). The ossiculoplasties were performed with either partial prosthesis techniques from the stapes superstructure to the drum, malleus, or malleus/drum (as is traditionally reported by most authors) or with less frequently advocated total prosthesis techniques from the stapes footplate to the drum, malleus, or malleus/drum. RESULTS/CONCLUSIONS: Of cases for which 1-year postoperative air and bone hearing results were available, group A cases had significantly smaller air-bone gaps than group C cases. There was no difference in mean air-bone gaps between partial and total reconstruction within either group A or C. A few partial and total prosthesis types had low failure rates, good mean air-bone gap hearing results, and tight spread of results to recommend them in group A cases. Total reconstruction had a lower prosthesis failure rate than partial reconstruction in group C cases, although mean air-bone gap hearing results were the same.

Streptomycin treatment in Menière's disease.

Streptomycin treatment in Menière's disease has traditionally been used for control of vertigo in patients with severe bilateral involvement or unilateral involvement in the only hearing ear. Guidelines for use that have worked at the Shea Clinic are presented. In addition, a special case is discussed in which this form of therapy has been used for treatment of fluctuant hearing loss in a patient with Menière's disease.

Sensorineural hearing loss in cordless telephone injury.

Audiometric data from 19 cases of cordless telephone injury are reviewed, including three cases with pre-insult and post-insult audiograms. In addition, data are presented from analyses of intensity and frequency for the ring signal of three telephones involved in injury cases. The most severe hearing loss was found at 500 Hz and 1000 Hz, where the mean threshold difference in the injured ear was 20 dB and 29 dB, respectively. The three cases for which pre-insult and post-insult data were available exhibited similar audiometric patterns, although the degree of threshold shift varied. Spectral analysis of the ring signal indicated sound-pressure levels of approximately 140 dB, with a fundamental frequency near 750 Hz.

Low-frequency harmonic acceleration in the evaluation of patients with intracanalicular and cerebellopontine angle tumors.

The application of low-frequency harmonic acceleration (HA) with the rotary chair is becoming more widespread in the clinical evaluation of the vestibular system. In the last 2 years, 18 patients with surgically or radiologically confirmed intracanalicular or cerebellopontine angle tumors have been evaluated with this clinical modality. In all cases (100%)--which included seven small tumors--vestibular evaluation with HA was abnormal. Slow harmonic acceleration, as is the case with other methods of vestibular evaluation, is not specific for acoustic tumors. Its great sensitivity in detecting peripheral vestibular abnormalities, however, may make it a useful addition to the test battery in the evaluation of patients with suspected intracanalicular or cerebellopontine angle tumors.

A simple autologous fibrinogen glue for otologic surgery.

A simple method of concentrating a patient's own fibrinogen for use with a thrombin/calcium solution--to produce a coagulum-type tissue glue for otologic surgery--is presented. The principal advantages of this system include a simple modification of the cryoprecipitate technique, which can be easily performed in any hospital laboratory using a minimal amount of the patient's blood, and the use of autologous fibrinogen, which completely rules out the possibility of transmission of hepatitis or AIDS viruses. Useful tips on preparation and use of this autologous tissue glue, based on experience over the past 2 years, will be presented.

Long-term experience with biocompatible ossicular implants.

The senior author's 8-year personal experience with biocompatible ossicular implants is reviewed. Four hundred sixty-one consecutive operations, in which high-density polyethylene sponge ossicular replacement prostheses were used, are grouped according to the Bellucci classification of chronic otitis media. The prostheses used were the drum-to-footplate prosthesis (TORP, total) and the drum-to-stapes prosthesis (PORP, partial). Each group's short- and long-term hearing results are compared. Prosthesis extrusion and persistent or recurrent conductive hearing loss are the most common causes of operation failure. Failures within each group are analyzed, and techniques to prevent these complications are outlined.

Nonsurgical management of small and intracanalicular acoustic tumors.

It is generally accepted that the proper treatment for acoustic tumors is surgical removal. In fact, there is little, if any, reference to nonsurgical treatment of these tumors in the recent medical literature. We would like to report on the nonsurgical management of six patients with cerebellopontine angle tumors based upon CT examination. The diagnostic findings, follow-up data, and the rationale upon which the decision was made to treat the patients nonsurgically will be presented, as will a review of the pertinent literature.

Intensity and frequency of sound levels from cordless telephones. A pediatric alert.

Recent reports have established that the ring of a cordless telephone is sufficient to produce hearing loss. In the present study, the intensity and frequency spectrum of the ring signal for three cordless telephones known to be involved in reported cases of acoustic trauma are presented. The potential hazard to hearing is reviewed, the implications for the pediatric community discussed, and the recommendation made that unmodified cordless telephones be kept out of the reach of children.

Nonsurgical management of small and intracanalicular acoustic tumors.

Although surgical removal is generally regarded as the management strategy of choice for acoustic tumors, there remains a small group of patients usually with small or intracanalicular tumors in whom nonoperative management may be a desirable alternative to operation. The authors present a series of six such cases and discuss criteria that may aid in the selection of patients suitable for initial nonoperative management.

Peg-tip fixation of Plasti-Pore TORP.

When inserted into a small hole drilled in the footplate, the peg-tipped Plasti-Pore TORP has given good hearing gain, without complications in a small series of patients.

Reconstruction of the posterior canal wall with Proplast.

Many ears with prior radical or modified radical mastoidectomy operations can be rehabilitated by reconstruction of the posterior canal wall with the porous biocompatible implant material Proplast. Many techniques have been advanced for reconstruction of the posterior canal wall and/or obliteration of the mastoid bowl. We prefer reconstruction of the posterior canal wall to obliteration of the mastoid bowl on the theoretical grounds that with obliteration you lose the pneumatic buffer of the mastoid air cell system and you might be burying infection and/or cholesteatoma in the depths of the mastoid. In this article we shall present our results with elimination of the open mastoid bowl by reconstruction of the posterior canal wall with Proplast. A retrospective study of 83 consecutive patients who underwent reconstruction of the posterior canal wall with Proplast during the 5-year period 1974 to 1978 was undertaken. The surgical technique consisted of rebuilding the tympanic membrane, when necessary, repairing the ossicular chain, when necessary, and reconstructing the posterior canal wall. The overall success rate for the posterior canal wall reconstructions was 46% (38 of 83). However, after modifications were made in the technique, especially in the use of thicker fascia and/or perichondria and periosteum over the Proplast, the success rate increased dramatically to 68% (19 of 28).

Use of the smooth Teflon clip to prevent pulmonary embolism in the postoperative period.

This report details experience with 50 patients who had vena caval interruption with a smooth Teflon (Moretz) clip placed at the time of surgery for other conditions in a high-risk patient population. No fatal pulmonary emboli were encountered; one patient developed bilateral iliofemoral venous thrombosis during the immediate postoperative period (Table 9). Another patient developed iliofemoral venous thrombosis and a nonfatal embolus two years after the vena caval interruption. Two patients developed postoperative edema, but no incapacitating edema and no ulcers were noted. Many of our patients were subjected to further risk of venous thrombosis and pulmonary embolism when hospitalization for medical care or operative procedures was required subsequent to the initial procedure. Vena caval interruption with a smooth Teflon clip can be recommended to prevent pulmonary embolism in high-risk patients who require surgery and to provide continuing protection during subsequent illness; however, extremity sequelae are minimal.

Thrombosis at the site of interruption of the vena cava: a consideration in prophylactic treatment of pulmonary embolism.

This study confirms the method of Ratnoff in inducing the hypercoagulable state in dogs, and further demonstrates that there is a varying thrombogenic factor when the vena cava is interrupted by ligation, staple plication, suture plication, serrated clip, and a smooth clip. The incidence of thrombosis caused by ligation, staple plication and suture plication would suggest that these are not suitable methods for prophylactic use. That no thrombosis occurred with the smooth clip would suggest that as a prophylactic measure, the smooth clip may be preferable to a serrated clip.

Immediate assessment of vascular operations using segmental plethysmography.

Segmental plethysmography was used as a monitoring device during 156 direct vessel operations on the abdominal aorta and lower extremity vessels. Patency of distal vessels was assessed continuously and noninvasively before and during wound closure. A pulsatile response at wound closure was indicative of immediate and lasting patency in 94 per cent of extremities monitored. Plethysmographic detection of acute intraoperative occlusive phenomena allowed correction of such problems during the same procedure. The "chronic nonpulsatile" plethysmographic response, although not indicative of accidental occlusions in the majority of cases, portended a poor result, primarily on the basis of insufficient collateralization around pre-existing distal occlusive disease. Patients with such responses should be considered for additional efforts at revascularization. Segmental plethysmography is a reliable and objective method of immediate assessment of vascular patency and for prediction of long-term results.